Francesca Comyn writes:
Praveen tells reporters outside Savita’s inquest that today is their wedding anniversary.
Praveen Halappanavar (above) arriving with his legal team to the last day of his wife, Savita’s inquest in Galway this morning.
(Laura Hutton/Photocall (Ireland)
Dr Peter Boylan tells inquest that #Savita would be alive if she had received a termination on Mon but this was not possible due to law
— Marie Madden (@dontmaddenme) April 17, 2013
Former Master of the National Maternity Hospital Dr Peter Boylan gives evidence as an expert witness at Savita Halappanavar’s inquest.
Dr Jennifer Gunter is a Canada-based, obstetrician/gynecologist and author of the book,The Preemie Primer.
She has followed the Savita Halpanaavar case from the first week the story broke in November of last year (top) on her blog.
Dr Gunter has given us permission to post her latest analysis of the inquest concerning the testimony of microbiologist Dr Susan Knowles (above).
As the inquest into Savita Halappanavar’s death continues we have heard about delays and errors, all of which most likely contributed to her terrible outcome.
However, along the way those who have tried to pass off her death as medical negligence and nothing to do with Irish law or Catholic ethos have rested on the assertion that she wasn’t sick enough to need a termination.
One of the experts at the inquest, Dr. Susan Knowles, a microbiologist at the National Maternity Hospital in Dublin is reported in the Irish Times as saying there wasn’t a substantial risk to Ms. Halappanavar’s life before Wednesday at 6:30 am. While she admits to what she calls “subtle indicators” of sepsis and chorioamnionitis (infection of the fetal membranes), she asserts these findings were just not enough to warrant a termination.
She is wrong.
By the Monday morning, less than 24 hours after admission, Savita had a white blood cell count of 16.9 and ruptured membranes. She also had pain. This would be enough to prompt every OB/GYN I know in the United States and Canada to discuss evacuating the uterus, or at least gather more evidence to say it is safe not to hold off and watch and wait. The standard of care in North America is “expeditious delivery” and antibiotics when chorioamnionitis is diagnosed, not wait until this get worse.
By Tuesday evening Savita had shaking chills and an elevated heart rate. This means the infection had now spread from the uterus to her blood stream. This is what happens when chorioamnionitis is inadequately treated. At this point my colleagues and I would be panicking about Ms. Halappanavar’s health. Not so in Galway. Dr. Knowles didn’t think things were bad enough until the next day.
If the diagnosis of chorioamnionitis is in doubt there are ways to be more certain, although keep in mind, Savita’s risk of infection was 30-40% the second her membranes ruptured early Monday morning so the burden of proof for infection in such a setting is low.
Her white blood cell count (WBC, a marker of infection) was apparently 16.9, which is very suspicious, but looking at specifics of the white blood cell count (the neutrophil count and the presence of bands, which are immature neutrophils) could have provided more about the possibility of a bacterial infection. An elevated neutrophil count or a bandemia would all but confirm chorioamnionitis in this clinical setting. An amniocentesis could also be performed if the diagnosis of chorioamnionitis were in doubt.
One could argue that the diagnosis of chorioamnionitis wasn’t in doubt as the team started antibiotics on the Monday evening, although say, just for the sake of argument, that the antibiotics were started as prevention. In this case, as infection was obviously suspected why wasn’t more done to confirm the diagnosis or rule it out?
Was the maternity ward at Galway that much of a fuck up that no one, from nursing student all the way up to senior staff, could possibly conceive of the idea that a woman with ruptured membranes at 17 weeks might actually have an infection?
Or didn’t it matter, because Savita was pregnant with a 17 weeks fetus that had cardiac activity but a 0% chance of survival. If Savita had to be sick enough to have a termination why bother confirm a diagnosis that no one could do anything about? Did the staff feel the only treatment that they could legally give was antibiotics so there was no point in knowing more?
Dr. Knowles’ testimony confirms for me that the law played a role, because her statements indicate the standard of care for treatment of chorioamnionitis is less aggressive in Ireland. This can only be because of the law as there is no medical evidence to support delaying delivery when chorioamnionitis is diagnosed.
Standard of care is not to wait until a woman is sick enough to need a termination, the idea is to treat her, you know, before she gets sick enough. An elevated white count and ruptured membranes at 17 weeks is typically enough to make the diagnosis, so Dr. Knowles needs to testify as to what in Savita’s medical record made it safe to not recommend a delivery.
By the way, I also disagree with Dr. Knowles about her interpretation of Savita’s medical record, the chart doesn’t have “subtle indicators” of infection, it screams chorioamnionitis long before Wednesday morning.
In North America the standard of care with chorioamnionitis is to recommend delivery as soon as the diagnosis is made, not wait until women enter the antechamber of death in the hopes that we can somehow snatch them back from the brink.
If Irish law, or the interpretation thereof, had nothing to do with Savita’s death no expert would be mentioning ‘sick enough’ at all.
Previously: An OB/GYN Writes
(Laura Hutton/Photocall Ireland)
Consultant Microbiologist Dr Susan Knowles (above) has told the inquest that there was poor documentation of the patient’s worsening condition.
She said most medical notes from a crucial period of the onset of sepsis were made retrospectively.
Some were made shortly after the events of the afternoon of Wednesday 24 October but others were added on 7, 8 and 12 November.
(Laura Hutton/Photocall Ireland)
Irish inquest hears Indian’s abortion refusal was ‘Catholic thing’ f24.my/14cK2r7
— FRANCE 24 (@FRANCE24) April 10, 2013
Mid-wife Ann Marie Burke, at Galway Courthouse today
Ms Burke said she was giving Mrs Halappanavar information because she was puzzled.
“She had mentioned the Hindu faith and that in India a termination would be possible,” Ms Burke said.
She said the remark had “come out the wrong way and I’m sorry that I said it”.
“I was trying to be as broad and explanatory as I could. It was nothing to do with medical care at all,” she added.
Midwife confirms she told Savita Halappanavar Ireland a ‘Catholic country’ (RTE)
(Laura Hutton/Photocall Ireland)
Coroner Dr Ciaran McLoughlin has told the inquest he has never seen so many retrospective notes in records before. #Savita
— Fergal Bowers (@FergalBowers) April 10, 2013
Midwife at #savita inquest admits using catholic country phrase. Regrets it now
— Brian Daly (@briandalytv3) April 10, 2013
Earlier: A Flurry Of Retrospective Notes.
(Laura Hutton/Photocall Ireland)
Praveen Halappanavar has started giving evidence, saying that #savita found Ireland “peaceful” and was “very popular” in the local community
— Marie Madden (@dontmaddenme) April 8, 2013
(Laura Hutton/Photocall Ireland)
The HSE’s draft report into the death of Savita Halappanavar says that difficulty in interpreting the law on abortion by the medical personnel at Galway University Hospital was a factor in the case, RTÉ News has learned.
Earlier: Unfinished Business
The husband of Savita Halappanavar is not satisfied with the conclusions of the final draft HSE report into her death, his solicitor Gerard O’Donnell has said.
The final draft report of the investigation team chaired by Prof Sir Sabaratnam Arulkumaran, head of obstetrics and gynaecology at St George’s Hospital, University of London, was given to Praveen Halappanavar on Friday.
Mr O’Donnell said his client had instructed him to seek a meeting with Prof Arulkumaran later this week to outline his concerns.
[…]
“It’s a report trying to establish what happened without naming anybody. So from Praveen’s point of view he wants to find out why this happened, why she was not treated, why she did not get treated.”
Savita husband not happy with HSE report into death (Kitty Holland, Irish Times)
(Brian Farrell/Photocall Ireland)
